Abnormal Uterine Bleeding Evaluation Note

[Encounter date and time]

[Note author and role]

[Location]

[Source of history and reliability assessment]

[Interpreter: language and modality]

(Only include if interpreter was used)

[Chaperone: name and role]

(Only include if chaperone was present)

Chief Complaint

"[Chief complaint in patient's own words]" (One line; quote if brief. If multiple concerns, list bleeding complaint first.)

Safety Assessment

[Hemodynamic status summary]

(For stable patients with mild symptoms, condense to a single sentence confirming stability and absence of emergent features. For moderate-to-severe or acute bleeding, include details below.)

• [Vital signs including orthostatics if dizziness, syncope, or significant blood loss suspected]
• [General appearance and perfusion status]
• [Red flag assessment: syncope/presyncope, chest pain, dyspnea, severe weakness, severe pelvic pain, fever, continuous flooding, known bleeding disorder, anticoagulant use]
• [Immediate interventions and rationale]

Pregnancy Exclusion

LMP: [Date / unknown]

Sexual activity and contraception context: [Brief summary]

Pregnancy test: [urine / serum], [result], [date/time performed]

[Pregnancy test not obtained: specific reason and clinician rationale; alternative plan or precautions reviewed]

(Only include if pregnancy testing not performed due to patient declined, prior hysterectomy, confirmed menopause, or other documented reason.)

History of Present Illness

[Narrative summary of bleeding concern including onset, duration, progression, context, modifying factors, and functional impact]

Bleeding characterization: [Cycle length/frequency], [duration of episodes], [regularity/predictability], [flow volume with quantification: pad/tampon counts, overnight changes, clot size, flooding, functional interference], [intermenstrual bleeding pattern], [postcoital bleeding], [unscheduled bleeding on hormonal method with adherence assessment]

Anemia symptom inventory: [Lightheadedness/presyncope], [fatigue], [exertional dyspnea], [palpitations], [prior anemia or iron therapy], [transfusion history]

Associated gynecologic symptoms: [Pelvic pain or pressure], [dysmenorrhea severity], [bulk symptoms], [dyspareunia]

Gynecologic background: [Menarche age] (especially for adolescents), [baseline cycle pattern before current problem], [recent pregnancy or pregnancy loss], [contraception history], [future fertility goals]

Medical contributors and medications: [Anticoagulants/antiplatelets with dose and indication], [hormonal therapies with dose and adherence], [thyroid symptoms or history], [PCOS features if present], [relevant systemic diseases: liver, renal, hematologic]

Bleeding disorder screen: [Easy bruising], [epistaxis], [gum bleeding], [postpartum hemorrhage], [surgical/dental bleeding complications], [known coagulopathy], [family history of bleeding disorders]

(Include when heavy bleeding since menarche or personal/family bleeding history suggests coagulopathy.)

Review of Systems

[Targeted ROS findings: constitutional, cardiopulmonary, endocrine, hematologic, GI/hepatic, GU/pelvic]

(Include only systems relevant to differential and workup.)

[ROS not obtained: reason]

(Only include if ROS deferred.)

Past Medical and Surgical History

• Medical: [Anemia, bleeding disorders, endocrine disorders, thromboembolism history or risk factors, other relevant conditions]
• Surgical: [Uterine/cervical procedures, other relevant surgeries]
• Medications: [Current medications; include dose and adherence for hormones and anticoagulants]
• Allergies: [Drug and non-drug allergies with reaction type]
• Family history: [Bleeding disorders, gynecologic malignancies with age at diagnosis]
• Social history: [Tobacco use status]

Physical Examination

Vitals: [BP, HR, RR, Temp, SpO2] (Include orthostatics when indicated.)

General: [Appearance, pallor, distress level]

Abdominal: [Tenderness, masses, distension, peritoneal signs]

Pelvic exam: [Consent obtained; chaperone present]

• External genitalia: [Findings]
• Speculum: [Source of bleeding: cervical vs uterine], [lesions], [discharge], [cervical findings]
• Bimanual: [Uterine size/contour], [tenderness], [adnexal findings], [cervical motion tenderness]

[Pelvic exam deferred: specific reason; alternative evaluation plan]

(Only include if deferred due to patient preference, age/indication, telehealth, or trauma history.)

Diagnostics

Completed Today

• Pregnancy test: [Type, result, time] (Required when pregnancy is possible.)
• CBC: [Result summary and interpretation regarding anemia severity]
• Type and screen: [Result]
(Include if severe bleeding or symptomatic anemia.)
• Directed labs: [Test, indication, result, interpretation]
(Include coagulation/VWD testing, thyroid, STI, or endocrine studies based on clinical indications.)
• Imaging: [Pelvic ultrasound: TV/TA components, findings, interpretation]

Previously Available

• [Test type, date, source, pertinent results/interpretation]

Ordered Today (Pending)

• [Labs ordered with indication]
• [Imaging ordered with indication]
(Consider sonohysterography or hysteroscopy if intracavitary pathology suspected; MRI for surgical planning.)

Endometrial Evaluation

Indication: [Age ≥45 / risk factors for hyperplasia / persistent bleeding / failed medical therapy / concerning imaging]

Method: [Office biopsy / hysteroscopy-directed] with rationale

Deferred: [Reason and timing plan]

(Only include if endometrial sampling not performed; document specific rationale.)

Assessment

[2-4 sentence summary synthesizing: bleeding pattern characterization, pregnancy exclusion status, hemodynamic stability and anemia severity, and leading suspected etiologies. Use "suspected" unless imaging or pathology confirms diagnosis.]

Differential diagnosis (PALM-COEIN):

(Include only clinically relevant categories with supporting/opposing features and clarifying workup.)

• Structural (PALM): [Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia considerations with evidence for/against]
• Non-structural (COEIN): [Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not otherwise classified considerations with evidence for/against]

Plan

1. Abnormal Uterine Bleeding

   • Stabilization: [IV access/fluids, medical options considered, contraindications assessed, escalation criteria]
   (Include for acute or moderate-severe presentations.)
   • Diagnostic plan: [Labs, imaging, endometrial sampling with indications and timing]
   • Maintenance therapy: [Selected treatment: LNG-IUS / tranexamic acid / NSAIDs / combined hormonal contraception / cyclic progestogens / other] based on [suspected cause and fertility goals]; contraindications screening and shared decision-making documented
   • Structural pathology management: [Procedural options, consults, referrals]
   (Include if structural pathology confirmed or highly suspected.)
   • Self-monitoring: Bleeding diary recommended

2. Iron Deficiency/Anemia

   (Include if present.)
   • [CBC interpretation and severity classification]
   • [Iron repletion: oral vs IV; dose, frequency, duration]
   • [Follow-up labs: timing for hemoglobin/ferritin reassessment]

3. Contraception/Reproductive Goals

   (Include when relevant.)
   • [Pregnancy intentions]
   • [Contraception plan aligned with AUB therapy; contraindication screening documented]

Return Precautions and Follow-up

Emergency precautions: Return immediately for soaking pads/tampons hourly, syncope, chest pain, dyspnea, worsening weakness, severe pelvic pain, or fever.

Follow-up: [24-72 hours for acute presentations / 2-12 weeks for chronic AUB] (Specify exact timing based on acuity and treatment plan.)

Procedures

(Include this section only if a procedure was performed.)

• Procedure: [Endometrial biopsy / IUD placement / other]
• Indication: [Clinical indication]
• Consent: [Risks, benefits, alternatives discussed; patient consented]
• Technique: [Anesthesia, preparation, steps, devices, findings]
• Specimens: [Description and destination]
• Complications: [None / details]
• Post-procedure instructions: [Care, activity restrictions, warning signs]